mTrac

Health information is an important building
block in any health system. To be effective, information must be
reliable and produced, analysed, and disseminated in a timely manner. These
data are used to inform decision-making that improves programmes and health
systems performance that ultimately impact the health status of a population.

Health management information systems (HMIS) often
provide historical accounts or audits that identify gaps and failings long
after they needed to be addressed. mTrac is used to course-correct mid-process
as challenges arise.

Like many other countries, Uganda uses DHIS 2,
a health management information system that helps governments manage their
operations, monitor processes and indicators, improve communication, and
visualise data. Health centres were required to hand in
paper-based surveillance data forms to their District Health Office on a weekly
basis, travelling great distances and at great expense. These reports were
inefficient, time-consuming, and regularly delayed by the poor transport
network within Uganda. One Nursing Assistant at a health centre level 2 had
this to say in relation to the reporting issues:

“I used to cry whenever it came to submitting
weekly surveillance data to the District Health Office because I had no
information records from which I could get the information. I wasn’t collecting
that information because I knew I couldn’t be able to transport it to the
district and neither did I have airtime to call the district every week.”

These delays in weekly information caused
significant bottlenecks in the drug supply chain. Though there is no shortage
of medicine at the national level, supplies weren’t reaching local clinics when
they were needed so people seeking treatment at clinics were finding that
essential medicines were not always in supply.

Approach

In partnership with UNICEF, WHO, and DFID, the
Ministry of Health decided to change the face of health service delivery in
Uganda with mTrac. mTrac is a mobile phone-based health information
systems strengthening tool that facilitates the flow of relevant and timely
data into Uganda’s national health management information system (HMIS) using
SMS.

HMIS

The health management information system was
the entry point for mTrac. DHIS 2’s Form 033b: Health Unit Weekly Epidemiological
Surveillance Form was selected for the relevance of information collected, the
importance of timely follow up and action, and historical challenges health
facilities faced in sending the form in on a routine basis. The form collects critical
data on morbidity and mortality for specific diseases, the out patient
department, eMTCT, malaria, and inventory of tracer medicines and HIV testing
kits. This information was broken into separate strings sent over SMS using
code words that mTrac processes and interprets. As a result, records
assistants, HMIS officers, and nurses throughout Uganda use their own mobile
phones to send 8 coded SMS messages to a toll-free short code each Monday. Health care workers can also submit alerts should they diagnose a notifiable disease during the week.

Similarly, village health teams (VHTs) in selected Integrated Community Case Management districts provide
information at the community level. VHTs are composed of volunteer health
workers who provide first line healthcare service to families in their
communities. VHTs submit weekly data through SMS on their existing HMIS
paper form 095, the VHT register. The data submitted includes the number of
identified cases of malaria, incidence of severe malnutrition, and cases
referred to the nearest health facility, as well as stock of artemisinin-based
combination therapy for malaria and Amoxicillin for bacterial infections.

mTrac either repeats the data back to the user
to check the accuracy of the submission, or sends an error message with a
prompt to correct the error. The entire process can take as little as five
minutes. Data are transmitted through mTrac to a central server, where they are
tabulated, aggregated, and graphed on a customised dashboard for District
Health Teams (DHTs) and selected national stakeholders to review, verify, and
approve. For early detection of outbreaks, mTrac sends alerts to District
Health Teams and appropriate health centres when an SMS report includes
incidence of a notifiable disease. To ensure adequate supply of medicine, mTrac
sends alerts when an SMS report indicates a drug stock out.The dashboard also includes
a mechanism for District Health Teams to communicate with those who report in
over SMS. They may need to contact a health worker to verify or correct
suspicious data or follow up on missing reports.

Once the Health Facility
Reports are approved, data are automatically updated in the DHIS 2 database and
then used to generate reports and share information via email
to Ministry of Health Departments, District Health Offices, and partners.
Accurate and timely data are collected, compiled, transmitted, reviewed,
approved, and shared on a weekly basis. mTrac extends the
national reach of DHIS 2 all the way down to the facility level.

The mTrac system provides basic data analysis
in each district. District biostatisticians and HMIS officers are able to view
trends in drug stock levels, disease incidence and health facility reporting
performance. Armed with this trend data, district teams are able to make more
informed management decisions such as re-distributing drugs and initiating
responses to disease outbreaks.

With the introduction of mTrac, many of the
logistical issues affecting health centre’s weekly reporting were addressed,
leading to reduced drug stock outs and early detection of outbreaks.

Early
detection of outbreaks

mTrac
facilitated the quick response, isolation, and treatment of symptoms to contain
the following outbreaks:

Ebola
Virus, Kibaale District, July 2012

Cholera,
Ntoroko, October 2012

Marburg
Virus, centred around Kabale, November 2012

Before
mTrac, it was very difficult to contact frontline health workers to provide
them with critical, real-time information during emergencies. But with mTrac, the
MoH national response team can quickly prepare a series of SMS messages to
alert health workers of each outbreak, the case definition (symptoms),
isolation procedures, the location of the nearest isolation facility, and the
hotline to the national response team to report suspected cases. The Ministry
of Health and DHTs were able to respond to the cholera outbreak in a matter of
hours. And during the Marburg outbreak, the Ministry of Health sent a total of
9,900 SMS messages to 825 health workers, DHTs and VHTs across 5 districts. The
ability to communicate directly to health workers ensures that they have the
information they need to respond to imminent public health emergencies and
minimise the impact on the Ugandan people.

“We don’t have to spend money on fuel to drive to National Medical Stores just
to enquire about drugs. We simply SMS and this triggers an immediate response
that culminates in delivery of medicines to the health facility...” so that
more patients can be treated with available medicines.

Health
Service Anonymous Hotline

In addition to health worker reports, mTrac
supports an anonymous hotline for community monitoring and accountability. The
anonymous hotline is an avenue for Ugandan citizens to provide feedback about
the quality of health services in their area and communicate directly with
District Health Teams and the Ministry of Health. Individuals type a
message with detailed information and then text it to short code 8200. mTrac
replies with an automated confirmation, and the message is reviewed by a dedicated
team at the Ministry of Health who categorises them by district and issue area
(e.g. general
complaint; stock-out of essential medicine; health staff negligence; fraud,
drug theft, or impersonation of health workers; health worker absenteeism)
before they’re made available to District Health Teams on the mTrac dashboard.
District health teams are first in line to follow up and investigate based on
the information provided. Incidents can also be forwarded to appropriate third
parties like the National Medical Stores and the Medicines and Health Medicines
Delivery Monitoring Unit when the issue falls outside of DHT’s scope. Follow-up
actions are tracked on the dashboard.

Since 2012, the hotline has received 14,588 actionable reports. The Health Monitoring Unit has responded with the following:

Visits to 1,268 health
facilities, contributing to the prevention of maternal and newborn deaths

Investigations of 2,066 criminal reports. One hundred cases were
referred to the courts, which led the recovery of stolen equipment and
medicines valued at $408,488 in 2013 alone.

The hotline
provides districts with the opportunity to receive feedback and respond to health
service delivery issues raised by citizens, which has generated a lot of
discussion within districts. Some districts are printing the anonymous messages
on a weekly basis, sharing them with the District Health Management Team and
partners, investigating, and resolving issues like disrespect from health
workers, health worker absenteeism, and stock outs. They use the information to
improve their image since they are seen as being responsive to the concerns of
the community.

Rapid Surveys

In preparation for a new vaccination campaign,
the Uganda National Expanded Programme on Immunization (UNEPI)
used mTrac to conduct a series of rapid SMS surveys. Pneumococcal Conjugate
vaccine (PCV) requires a cold chain supply, so UNEPI wanted to assess vaccine
supply and cold chain functionality to resolve issues that would impact the
effectiveness of vaccination efforts.

On April 26, 2013, health staff at 3,240
facilities received the following poll:

"Does your Health Unit have a cold chain fridge for
vaccines? Please answer YES / NO. If you have a fridge but it is not working,
please tell us about it.”

Within two days, UNEPI had actionable
data from 1,862 facilities (57.5% of the total target), identifying
194 facilities with resolvable issues like gas stock-outs
or minor mechanical issues.

Even where cold chain fridges were
functioning properly, a follow-up mTrac rapid survey on supply showed that
stock-outs would also inhibit the success of the PCV campaign. On May 19, 2013,
a second poll was sent asking health workers:

"Do you have any stock-outs of key vaccines, YES or
No. If Yes, please tell us which you have no stock."

Tapping into the mTrac database of
over 16,000 registered health workers, UNEPI was able to survey thousands of health
facilities and analyse results within 48 hours at cost of less than $150 USD
per poll. With the appropriate information, UNEPI was able to
respond to these actionable data before the launch of the PCV campaign. As a direct result of these rapid surveys, the MoH, UNICEF, WHO
and partners conducted an urgent review with the National Medical Stores that
identified drivers of vaccine stock-out, provided a cold chain consultant, and
streamlined vaccine distribution. In addition to a successful PCV campaign, these
actions led to a remarkable increase in immunization coverage of DPT1 from 52% to
98% over the course of one year.

This work around supply also reduced stock-out
of ACTs for malaria from 60% in 2012 to 13% in 2014 with an estimated 132,000
children under 5 treated per year.

Family Health Days

mTrac was originally designed to improve
reporting on disease surveillance and supply of essential
medicines, provide a mechanism to receive feedback from the community, and
identify issues with healthcare delivery, but mTrac has expanded since its
inception in December 2011. The Ministry of Health (MoH) is now using the
platform for other critical life-saving measures in a partnership with UNICEF
and faith-based organisations. Family Health Days were designed to reach
populations living in hardship areas where access to healthcare is limited. A
free and integrated package of health interventions is provided on a quarterly
basis following religious services. Interventions include deworming, antenatal
care for pregnant women, birth registration and immunisation for children under
the age of 5, counselling and education on health lifestyles for youth, and
blood pressure checks for fathers accompanying their spouses. Through Family
Health Days, traditional barriers to healthcare, such as long distances, have
been eliminated.

mTrac is supporting real-time data collection
within Family Health Days campaign, which has been implemented in 28 districts.
mTrac data have been used to improve planning and decision-making, including in
Yumbe district where the DHT was able to successfully address supply issues and
enable support access to much-needed healthcare services across the country.

By 2013, mTrac was fully operational nationwide,
making it the first and only mobile phone based health information system strengthening tool operating
at that scale anywhere in the world. mTrac now reaches all 112 districts, over 5,000
health facilities, 16,000 health facility workers, and over 5,000 community
health workers in Uganda.

mTrac demonstrates the impact that mobile
health technology can have in a resource-constrained environment. Future use
cases include medicine adherence reminders, referral management, and
appointment scheduling but these are just a few of unlimited possibilities. mTrac
will continue to play a role in the monitoring and delivery of health services
in Uganda.